Healthcare in the crossfire

As Mohammed Mohammedi lay trapped in the car with his co-worker, pinned down by heavy gunfire, they promised each other that whoever made it out alive would tell the other’s family. Now, 12 years after he was captured and beaten by militias in Somalia while carrying out a polio vaccination campaign, he realizes this was a “futile promise”.

“If you ask someone at WHO [World Health Organization], ‘What is the extent of the problem?’ [of attacks on health facilities and workers],” said Rudi Coninx, with the Emergency Risk Management and Humanitarian Response team at WHO. “If they were honest they would say, ‘I don’t know,' as nobody collects these data in a systematic way."

Mohammedi said he was released after clans who knew the polio vaccination health staff paid the militias. If he or his co-worker had died, there was no international mechanism, then or now, to record that he had been hurt while doing his job as a health worker.

“One of the first victims of war is the healthcare system itself,” wrote Marco Baldan, the chief war surgeon at the International Committee of the Red Cross (ICRC) in an August 2011 agency report, which noted that violence against healthcare is “one of the most crucial yet overlooked humanitarian issues of today".

Less than one year after launching this report, and a campaign to document and rein in violence against healthcare facilities and workers, the agency suspended its work in Pakistan after one of its programme managers was kidnapped and killed while travelling home in an ICRC vehicle.

Mohammedi, a WHO polio operation and technical officer now working in Pakistan, told IRIN that regardless of the precautions, humanitarians always face danger. “An agreement with the war-lords, clan, [or] military leader is the best valid agreement, though even that is not a 100 percent guarantee of a person’s safety.”

Fighting often hampers access for health workers in two of the four countries where polio is still endemic - Pakistan and Afghanistan.

Despite international conventions in place to protect health facilities, workers and marked vehicles, as long as they maintain a “neutral function and treat all patients equally, irrespective of political, religious or ethnic affiliation”, the Geneva Convention carries little authority with militias, said Mohammedi.

“Free access is not and will never be possible if the agreements are made by people sitting around a table outside of conflict areas. The militias have a different way of thinking - the only agreement for a militia at war is to kill… For the militia, a prisoner of war is still the enemy.”

The Geneva Convention forms a major part of negotiating access for the medical humanitarian NGO, Médecins Sans Frontières (MSF), but it is difficult when “non-state actors” never agreed to it in the first place, said Michiel Hoffman, a Brussels-based operational advisor to MSF.

Somalia is the only country where MSF is forced to use private guards to protect its health facilities, which is not ideal, but necessary, Hoffman told IRIN. “It is hard to provide healthcare when there is a general disregard for everyone’s lives,” he said. “To have any weapons near a health structure makes them the target of conflict.”

Health facilities have become even more vulnerable as soldiers increasingly enter hospitals to “settle scores”, said Robin Coupland, an ICRC medical advisor, in a January 2012 WHO bulletin.

From a review of internal and public sources, ICRC documented 655 violent events affecting healthcare in 16 countries in conflict from 1 July 2008 to December 2010, of which 41 percent were reported only in internal agency reports.

Documenting the extent of the problem is the first step to start doing something about it, said Coninx.

The “compounded cost” of violence on healthcare, such as healthcare staff fleeing, inventory stock-outs and curtailed vaccination campaigns are also hard to measure, ICRC noted.

On 21 January 2012, WHO’s executive board passed a resolution committing the agency to collecting and distributing data on attacks on health workers, facilities, vehicles and patients in the next two years.

UN member states will vote on this proposal on 25 May 2012 at the ongoing World Health Assembly in Geneva.